The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air out as if blowing up a balloon. Variations of the maneuver can be used either in
medical
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care practic ...
examination as a test of cardiac function and
autonomic nervous control of the
heart
The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide to t ...
, or to clear the
ear
An ear is the organ that enables hearing and, in mammals, body balance using the vestibular system. In mammals, the ear is usually described as having three parts—the outer ear, the middle ear and the inner ear. The outer ear consists of ...
s and
sinuses
Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sphenoid ...
(that is, to equalize pressure between them) when ambient pressure changes, as in
scuba diving
Scuba diving is a mode of underwater diving whereby divers use breathing equipment that is completely independent of a surface air supply. The name "scuba", an acronym for " Self-Contained Underwater Breathing Apparatus", was coined by Chr ...
,
hyperbaric oxygen therapy
Hyperbaric medicine is medical treatment in which an ambient pressure greater than sea level atmospheric pressure is a necessary component. The treatment comprises hyperbaric oxygen therapy (HBOT), the medical use of oxygen at an ambient pressure ...
, or
air travel
Air travel is a form of travel in vehicles such as airplanes, jet aircraft, helicopters, hot air balloons, blimps, gliders, hang gliders, parachutes, or anything else that can sustain flight. .
A modified version is done by expiring against a closed
glottis. This will elicit the cardiovascular responses described below but will not force air into the
Eustachian tubes.
History
The technique is named after
Antonio Maria Valsalva
Antonio Maria Valsalva (17 January 1666 – 2 February 1723), was an Italian anatomist born in Imola. His research focused on the anatomy of the ears. He coined the term Eustachian tube and he described the aortic sinuses of Valsalva in his wri ...
, a 17th-century physician and anatomist from
Bologna
Bologna (, , ; egl, label=Emilian language, Emilian, Bulåggna ; lat, Bononia) is the capital and largest city of the Emilia-Romagna region in Northern Italy. It is the seventh most populous city in Italy with about 400,000 inhabitants and 1 ...
whose principal scientific interest was the human ear. He described the
Eustachian tube and the maneuver to test its patency (openness). He also described the use of this maneuver to expel
pus
Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection ...
from the middle ear.
Physiological response
![valsalva3](https://upload.wikimedia.org/wikipedia/commons/1/1f/Valsalva3.jpg)
The normal physiological response consists of four phases.
# Initial pressure rise
#: On application of expiratory force, pressure rises inside the chest forcing blood out of the
pulmonary circulation
The pulmonary circulation is a division of the circulatory system in all vertebrates. The circuit begins with deoxygenated blood returned from the body to the right atrium of the heart where it is pumped out from the right ventricle to the lungs ...
into the
left atrium
The atrium ( la, ātrium, , entry hall) is one of two upper chambers in the heart that receives blood from the circulatory system. The blood in the atria is pumped into the heart ventricles through the atrioventricular valves.
There are two at ...
. This causes a mild rise in
stroke volume during the first few seconds of the maneuver.
# Reduced venous return and compensation
#: Return of systemic blood to the heart is impeded by the pressure inside the chest. The output of the heart is reduced and stroke volume falls. This occurs from 5 to about 14 seconds in the illustration. The fall in stroke volume reflexively causes blood vessels to constrict with some rise in pressure (15 to 20 seconds). This compensation can be quite marked with pressure returning to near or even above normal, but the
cardiac output and blood flow to the body remains low. During this time the pulse rate increases (compensatory tachycardia).
# Pressure release
#: The pressure on the chest is released, allowing the pulmonary vessels and the
aorta
The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes o ...
to re-expand causing a further initial slight fall in stroke volume (20 to 23 seconds) due to decreased left atrial return and increased aortic volume, respectively. Venous blood can once more enter the chest and the heart, cardiac output begins to increase.
# Return of cardiac output
#: Blood return to the heart is enhanced by the effect of entry of blood which had been dammed back, causing a rapid increase in cardiac output (24 seconds on). The stroke volume usually rises above normal before returning to a normal level. With return of blood pressure, the pulse rate returns towards normal.
Deviation from this response pattern signifies either abnormal heart function or abnormal
autonomic nervous control of the heart. Valsalva is also used by dentists following extraction of a
maxillary molar
The molars or molar teeth are large, flat teeth at the back of the mouth. They are more developed in mammals. They are used primarily to grind food during chewing. The name ''molar'' derives from Latin, ''molaris dens'', meaning "millstone to ...
tooth. The maneuver is performed to determine if a
perforation
A perforation is a small hole in a thin material or web. There is usually more than one perforation in an organized fashion, where all of the holes collectively are called a ''perforation''. The process of creating perforations is called perfor ...
or
antral communication
A dental extraction (also referred to as tooth extraction, exodontia, exodontics, or informally, tooth pulling) is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reason ...
exists.
Applications
Normalizing middle-ear pressures
When rapid ambient pressure increase occurs as in diving or aircraft descent, this pressure tends to hold the
Eustachian tubes closed, preventing pressure equalization across the ear drum, with painful results.
To avoid this painful situation, divers,
caisson workers and aircrew attempt to open the Eustachian tubes by
swallowing, which tends to open the tubes, allowing the ear to equalize itself.
If this fails, then the Valsalva maneuver may be used. This maneuver, when used as a tool to equalize middle ear pressure, carries with it the risk of auditory damage from over pressurization of the middle ear.
The Valsalva maneuver generates about 20–40 mm of Hg pressure. It is safer, if time permits, to attempt to open the Eustachian tubes by swallowing a few times, or yawn
A yawn is a reflex lasting 4-7 seconds, and is characterized by a long inspiratory phase with gradual mouth gaping, followed by a brief climax (or acme) with muscle stretching, and a rapid expiratory phase with muscle relaxation. For fish an ...
ing, or by using the Valsalva technique of breathing a very small amount of air gently into nostrils held closed by the fingers as soon as mild pressure is felt, before it increases to the point that its release would be painful. The effectiveness of the "yawning" method can be improved with practice; some people are able to achieve release or opening by moving their jaw
The jaw is any opposable articulated structure at the entrance of the mouth, typically used for grasping and manipulating food. The term ''jaws'' is also broadly applied to the whole of the structures constituting the vault of the mouth and serv ...
forward or forward and down, rather than straight down as in a classical yawn,[ and some can do so without moving their jaw at all by activating the ]tensor tympani muscle
The tensor tympani is a muscle within the middle ear, located in the bony canal above the bony part of the auditory tube, and connects to the malleus bone. Its role is to dampen loud sounds, such as those produced from chewing, shouting, or thu ...
, which is heard by the individual as a deep, rumbling sound. Opening can often be clearly heard by the practitioner, thus providing feedback that the maneuver was successful.
During swallowing or yawning, several muscles in the pharynx (throat) act to elevate the soft palate and open the throat. One of these muscles, the tensor veli palatini
The tensor veli palatini muscle (tensor palati or tensor muscle of the velum palatinum) is a broad, thin, ribbon-like muscle in the head that tenses the soft palate.
Structure
The tensor veli palatini is found anterior-lateral to the levator ve ...
, also acts to open the Eustachian tube. This is why swallowing or yawning is successful in equalizing middle ear pressure. Contrary to popular belief, the jaw does not pinch the tubes shut when it is closed. In fact, the Eustachian tubes are not located close enough to the mandible to be pinched off. People often recommend chewing gum during ascent/descent in aircraft, because chewing gum increases the rate of salivation, and swallowing the excess saliva opens the Eustachian tubes.
In a clinical setting the Valsalva maneuver will commonly be done either against a closed glottis, or against an external pressure measuring device, thus eliminating or minimizing the pressure on the Eustachian tubes. Straining or blowing against resistance as in blowing up balloons has a Valsalva effect and the fall in blood pressure can result in dizziness and even fainting.
Strength training
The Valsalva maneuver is commonly believed to be the optimal breathing pattern for producing maximal force and is frequently used in powerlifting
Powerlifting is a strength sport that consists of three attempts at maximal weight on three lifts: squat, bench press, and deadlift. As in the sport of Olympic weightlifting, it involves the athlete attempting a maximal weight single-lift effo ...
to stabilize the trunk during exercises such as the squat, deadlift
The deadlift is a weight training exercise in which a loaded barbell or bar is lifted off the ground to the level of the hips, torso perpendicular to the floor, before being placed back on the ground. It is one of the three powerlifting exercises ...
, and bench press, and in both lifts of Olympic weightlifting
Olympic weightlifting, or Olympic-style weightlifting (officially named Weightlifting), is a sport in which athletes compete in lifting a barbell loaded with weight plates from the ground to overhead, with each athlete trying to successfully lif ...
. Additionally, competitive strongmen often use the Valsalva maneuver in things such as log press, yoke walks, and stone loading, as well as any other strongman movements.
Pain management
The Valsalva maneuver can be used as a means to reduce pain during lumbar puncture. According to Kumar, et. al, performing the maneuver on an awake patient triggers predictable cardiovascular and autonomic responses that can be timed by a skilled surgeon to maximize anesthetic benefit for the patient.
Regulation of heart rhythm
The Valsalva maneuver may be used to arrest episodes of supraventricular tachycardia. Blood pressure (BP) rises at onset of straining-because the increased intrathoracic pressure (ITP) is added to the pressure in the aorta. It then falls because the ITP compresses the veins, decreasing the venous return and cardiac output. This inhibits the baroreceptors causing tachycardia and a rise in peripheral vascular resistance (PVR). When the glottis is opened and the ITP returns to normal, cardiac output is restored but the peripheral vessels are constricted. The blood pressure therefore rises above normal and this stimulated the baroreceptors, causing bradycardia and a drop in BP to normal level.
Medical diagnostics
Cardiology
The maneuver can sometimes be used to diagnose heart abnormalities, especially when used in conjunction with an echocardiogram
An echocardiography, echocardiogram, cardiac echo or simply an echo, is an ultrasound of the heart.
It is a type of medical imaging of the heart, using standard ultrasound or Doppler ultrasound.
Echocardiography has become routinely used in th ...
. For example, the Valsalva maneuver (phase II) increases the intensity of hypertrophic cardiomyopathy murmurs, namely those of dynamic subvalvular left ventricular outflow obstruction. At the same time, the Valsalva maneuver (phase II) decreases the intensity of most other murmurs, including aortic stenosis
Aortic stenosis (AS or AoS) is the narrowing of the exit of the left ventricle of the heart (where the aorta begins), such that problems result. It may occur at the aortic valve as well as above and below this level. It typically gets worse ov ...
and atrial septal defect
Atrial septal defect (ASD) is a congenital heart defect in which blood flows between the atria (upper chambers) of the heart. Some flow is a normal condition both pre-birth and immediately post-birth via the foramen ovale; however, when this d ...
. During the first few seconds of the Valsalva maneuver (phase I) the opposite findings will be the case.
A UK-based randomized controlled trial
A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical te ...
(REVERT) demonstrated that in patients with cardiovascularly stable supraventricular tachycardia, a modified Valsalva maneuver started in semi-recumbent position followed by repositioning of the patient to a supine position with a passive leg raise immediately after the strain has and increased 43% success rate compared to the only 17% effectiveness of the conventional Valsalva maneuver in terminating supraventricular tachycardia.
Neurology
The Valsalva maneuver is used to aid in the clinical diagnosis of problems or injury in the nerves of the cervical spine. Upon performing the Valsalva maneuver, intraspinal pressure slightly increases. Thus, neuropathies or radicular pain may be felt or exacerbated, and this may indicate impingement on a nerve by an intervertebral disc or other part of the anatomy. Headache and pain upon performing the Valsalva maneuver is also one of the main symptoms in Arnold–Chiari malformation
Chiari malformation (CM) is a structural defect in the cerebellum, characterized by a downward displacement of one or both cerebellar tonsils through the foramen magnum (the opening at the base of the skull). CMs can cause headaches, difficu ...
. The Valsalva maneuver may be of use in checking for a dural tear following certain spinal operations such as a microdiscectomy. An increase in intra-spinal pressure will cause cerebral spinal fluid
Cerebrospinal fluid (CSF) is a clear, colorless body fluid found within the tissue that surrounds the brain and spinal cord of all vertebrates.
CSF is produced by specialised ependymal cells in the choroid plexus of the ventricles of the br ...
(CSF) to leak out of the dura causing a headache.
The Valsalva maneuver has been associated with transient global amnesia
Transient global amnesia (TGA) is a neurological disorder whose key defining characteristic is a temporary but almost total disruption of short-term memory with a range of problems accessing older memories. A person in a state of TGA exhibits no o ...
.
Palpation of supraclavicular lymph nodes
As the lymph nodes may be buried, asking the patient to perform the Valsalva maneuver can push the cupola of the lung upward bringing deep-seated nodes to a more accessible position for palpation. Palpation may identify an enlargement of the supraclavicular lymph nodes which is a diagnostic indicator of cancer. The prevalence of malignancy in the presence of supraclavicular lymphadenopathy is reported to be in the range of 54% to 85%.
Oral–antral communication
A variant of the Valsalva maneuver is used to aid diagnosis of oral–antral communication, i.e. the existence of a connection between the oral cavity and the maxillary sinus
The pyramid-shaped maxillary sinus (or antrum of Highmore) is the largest of the paranasal sinuses, and drains into the middle meatus of the nose through the osteomeatal complex.Human Anatomy, Jacobs, Elsevier, 2008, page 209-210
Structure
It i ...
.
Urogenital medicine
The Valsalva maneuver is used to aid diagnosis of intrinsic sphincteric deficiency (ISD) in urodynamic tests. Valsalva leak point pressure is the minimum vesicular pressure that is associated with urine leakage. Although there is no consensus on the threshold value, values > 60 cm H2O are commonly considered to indicate hypermobility of the bladder neck and normal sphincter function. Also, when examining women with pelvic organ prolapse
Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting.
In m ...
, asking the patient to perform the Valsalva maneuver is used to demonstrate maximum pelvic organ descent.
Complications
Preretinal
Valsalva retinopathy is pathological syndrome associated with the Valsalva maneuver. It presents as preretinal hemorrhage (bleeding in front of the retina) in people with a history of transient increase in the intrathoracic pressure and may be associated with heavy lifting, forceful coughing, straining on the toilet, or vomiting. The bleeding may cause visual loss if it obstructs the visual axis, and patients may note floaters in their visual field. Usually this causes no permanent visual impairments, and sight is fully restored.
Valsalva device in spacesuits
Some spacesuits contain a device called the Valsalva device to enable the wearer to block their nose to perform the Valsalva maneuver when wearing the suit. Astronaut Drew Feustel describes it as "a spongy device called a Valsalva that is typically used to block the nose in case a pressure readjustment is needed". One use of the device is to equalize pressure during suit pressurization.
See also
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References
External links
Definitions of various clinical tests for neuropathy
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{{authority control
Aviation medicine
Diagnostic cardiology
Diving medicine
Ear procedures
Human physiology
Italian inventions
Underwater diving procedures